Cytokine pathways:
which one to target?
Pr Bernard KLEIN
Institute of Research for Biotherapy
Montpellier, FRANCE
http://irb.chu-montpellier.fr/
No conflict of interest
B. Klein, IMW Paris 2011
Primary Myeloma cells of patients with intramedullary
Myeloma are dependent on the environment for their survival
Patients with intramedullary
Patients with extramedullary
Myeloma
Myeloma
Recombinant
Death within
cytokines
12 days
In vitro growing cell lines
can be obtained
Purification
Of Myeloma
cells
Hematopoïetic
Adipocytes
cells
Myeloma
Stromal cells
cells
Endothelial
IGF-1, IL-6, IL-21,
cells
BAFF/APRIL, IFN, IL-10,
HGF, EGF, VEGF,
Osteoclasts
Osteoblasts
B. Klein,
Jagged/Notch IMW Paris 2011
Hierarchy of myeloma cell growth factors
using cell lines
1. IGF-1 is essential (particularly as an autocrine growth factor)
2. IL-6 is a major myeloma cell growth factor in all
myeloma cell lines
3. HGF, and EGF members, are less important (1/3 and
¼ of cell lines)
4. APRIL, triggers the growth of ¼ of cell lines
5. Other growth factors: IL-21, IFNa, VEGF,
Chemokines, Jagged, ...
Sprynski, Blood, 2009
B. Klein, IMW Paris 2011
IGF-1 is the main myeloma cell growth factor
(particularly as an autocrine growth factor), the other growth factors
being partly dependent on an autocrine IGF-1/IGF-1R loop
control
XG-2 Cell Line (requires exogenous cytokine to grow)
IL6 Inhibitor
IGF-1 inhibitor
ErbB inhibitor
HGF Inhibitor
100
80
r activity
cto
*
60
fa
*
owth 40
gr
*
*
*
*
20
the
*
*
Sprinsky,
of
Blood, 2009
%
0
IGF-1
IL-6
HGF
HB-EGF B. Klein, IMW Paris 2011
IGF-1 is the main myeloma cell growth factor, the other
growth factors being mostly dependent on an autocrine
IGF-1/IGF-1R loop
IGF-1
IL-6
IL-21
HGF
IGF-1R
EGF
CD45
Sprynski, Blood, 2009
Monoret, J Immunol, 2008
Amiot, J Immunol, 2006
B. Klein, IMW Paris 2011
IGF-1R is not expressed by normal plasma cells
Memory
Activated
Preplasmablast
Plasmablast
Plasma cell
B cell
B cell
CD19+CD20+CD38CD138
CD19+CD20
CD19+CD20
CD19+CD20
CD38CD138
CD38++CD138
CD38+++CD138+
Jourdan, Blood, 2009
IGF-1 is expressed
by plasmablasts and
expression
plasma cells
gene
IGF-1
B. Klein, IMW Paris 2011
IGF-1R is aberrantly expressed in malignant plasma cells
Primary myeloma cells of
Myeloma cell lines,
50% of the patients with newly
90% of cell lines
diagnosed myeloma
P53 loss or mutations
IGF-1R
Downregulation of p53-inducible
microRNAs 192, 194, and 215
(Pichiorri, 2010)
B. Klein, IMW Paris 2011
Increased frequency of patients with IGF-1R+
Myeloma cells in case of del17 or t(4;14)
Patients with
Del17 (n=24)
No Del17 (n=97)
IGF-1R+ Myeloma
58%
27%
cells
IGF-1R- Myeloma cells
42%
73%
Patients with
t(4;14)(n=20) No t(4;14) (n=74)
IGF-1R+ Myeloma
70%
26%
cells
IGF-1R- Myeloma cells
30%
74%
B. Klein, IMW Paris 2011
IGF-1R gene expression has prognostic value
independently of t(4;14)
B. Klein, IMW Paris 2011
The aberrant IGF-1R expression on malignant plasma
cell confers on insulin a potent myeloma cell growth
activity at physiological concentrations
High affinity
Insulin
IGF-1, IGF-2
Myeloma cells
Normal
Aberrant expression
Plasma cells
of IGF-1R
Aberrant hybrid
IGF-1R/INSR
Growth activity
Metabolic activity
Sprynski, Leukemia, 2010
B. Klein, IMW Paris 2011
9 responses in 27
patients in
combination with
dexamethasone
CP-751,871
recognizes the IGF-
1R/INSR hybrid
receptor
AVE1642 alone or in
combination with
Bortezomib.
No activity when the
antibody was used
alone.
1 CR and 1 PR in 11
patients in
combination with
Bortezomib
B. Klein, IMW Paris 2011
IGF-1 is mainly produced by osteoclasts and Myeloma
cells in the bone marrow of patients.
IGF-1 is a survival factor for osteoclasts
expression
gene
IGF-1
Moreaux, Blood, 2011
B. Klein, IMW Paris 2011
The anti-IGF-1R antibody has to diffuse in the bone marrow and block the
binding of IGF-1 that is largely produced by myeloma cells and osteoclasts.
Large levels of IGF-1 and of insulin also circulate in the plasma.
Adipocytes
Hematopoietic
Hematopoietic cells
cells
Stromal cells
Myeloma cells
Vessel
IGF-1
Anti-IGF-1R
antibody
Osteoclasts
Osteoblasts
B. Klein, IMW Paris 2011
Anti-cytokine therapy in association with high dose chemotherapy
After 4 courses of VEL-DEX
9 days after melphalan
8000 cells/l (16/22 patients)
400 cells/l
90 myeloma cells/
High dose
l
6 myeloma cells/l
5 normal plasma cells/l
melphalan
3 normal plasma cells/l
IL6 (pg/mL)
14 fold increase
The residual myeloma
Same for
other myeloma
cells are bathed in high
cell growth
levels of IL-6 and other
factors
myeloma cell growth
factors in an almost
empty bone marrow
B. Klein, IMW Paris 2011
Day -5
Anti-IL-6 antibody
Day 10
8000 cells/l
High dose
24 patients
90 myeloma cells/l
melphalan
5 normal plasma cells/l
No hematological toxicity
Less mucositis
54% in VGPR
Link between a complete
inhibition of CRP and VGPR
B. Klein, IMW Paris 2011
Cytokine pathways: which one to target?
IGF-1 and IL-6 are the two main myeloma cell growth factors.
IL-6 is a mandatory factor to generate normal plasma cells.
A phase 3 clinical trial with anti-IL-6 antibodies in association with Bortezomib is
ongoing.
IGF-1R is not expressed by normal plasma cells but IGF-1 is a plasma cell marker.
IGF-1R is aberrantly expressed by Myeloma Cells, in association with a poor
prognosis. There is a link with del17 and t(4;14).
Insulin is a powerful myeloma cell growth factor at physiological concentrations,
targeting hybrid receptors (IGF-1R/INSR).
Phase I studies with anti-IGF-1R antibodies show lack of toxicity but a poor
efficacy.
Identify therapeutic windows to make easier the diffusion of antibodies. Use of
small inhibitors. Combination of therapies using cytokine inhibitors with other
molecules.
B. Klein, IMW Paris 2011
Institute of Research in
Clinical Hematology, Heidelberg
Biotherapy
Hartmut Goldschmidt
INSERM U1040
Dirk Hose
Montpellier
Clinical Hematology, Montpellier
Anne Catherine Sprynski
Jean François Rossi
Jerôme Moreaux
Anouk Caraux
CHU Nimes
Michel Jourdan
Eric Jourdan
Lauren Vincent
Thierry Rème
Caroline Bret
Aboulkadel Kassambara
UAMS, Little Rock, USA
Matthieu Shoenhals
John Shaughnessy
Nicolas Robert
Bart Barlogie
B. Klein, IMW Paris 2011